Name:

Postcode:

Telephone No.:

I'd like Tom to give me a call to discuss my issues and concerns.

E-Mail:

I'd like to sign up to Tom's mailing list.

What is your number one concern nationally?

Education
Health
Crime
Defence
Environment
Transport
Other (please specify)

What is your number one concern locally?

Schools
Hospitals
Crime
Local services (e.g. libraries, refuse collections)
Transport
Other (please specify)

What do you think Tom's key local priorities should be?

How would you rate the performance of your local council?
1 - Very poor
2 - Poor
3 - Average
4 - Good
5 - Excellent

How would you rate the performance of the Government since 1997?
1 - Very poor
2 - Poor
3 - Average
4 - Good
5 - Excellent

In the next General Election, which party do you intend to vote for:
Labour
Conservative
Liberal Democrat
Other (please specify)

Please send me information about how to join the Labour Party

Many thanks for taking the time to complete this survey.